J.R.A.S. Vol. XXVII, No. 1-2, (2006) pp.41-51

'.

"THE ROLE OF PICHU (TAILA) APPLICATION INTHE MANAGEMENT OF ARSHA

(HAEMORRHOIDS)" - A PILOT STUDYM.Mruthyumjaya Rao', B.Das2, G.C.Nanda2 and M.M.Padhi2

(Received on 23.8.2005)

,A pilot study was conducted to see the

efficacy of "Pichu (Taila) application inthe treatment Arsha (Haemorrhoids) atAno-Rectal Clinic, Central Researchl nst it ute (Ay.), Bh uban eswar. Thisobservational (pilot) study was conductedOil 25patients of Arsha as per the Proformadesigned by CCRAS. New Delhi.

Out of25 cases who received the aboveregimen. 80 percent cases got completerelief. 12 percent got marked relief and 8

..•.percent got moderate relief Analysis wasmade to assess the results in relation tovarious aspects including improvement inhemoglobin levels. After analyzing theresults it is concluded that the above drugregimen is effective in Arsha management.

Introduction

Arsh a (Haemorrhoids) has beendescribed in Ayurveda one among theMahagadas and is generally translated ashaemorrhoids in modern terms. Thepatients with piles may have one or moreof a number of individual problems, thatno single treatment method can be advisedfor all patients and that several differentmethods may achieve actually good result.The ill defined derangement of anal canalfunction may produce symptoms singly orin combination: pain, bleeding, prolapse,mucus discharge, peri-anal itching,constipation and incontinence to flatus and!or faeces. Regarding the treatment of pilesthe least invasive procedure / treatment is

1Asst.Director (Ay.) 2 Research Officer (Ay.) Central Research Institute( Ay.) Unit-I,Bhubaneswar

41

M.Mruthyumjaya Rao, et at.

most desirable excepting few conditionsto treat the haernorrhoids. Several surgical!conventional therapies are now in practicedepending upon condition ofhaemorrhoidslike sclerotherapy, rubber band ligation,anal dilatation, photo coagulation,cryosurgery, haemorr-hoidectomy etc. ThisIncreasing number of therapies themselvesproves that there is no universallyacceptable technique in the managementofhaemorrhoids. Sushruta, recommendedfour different treatment modalities whichare widely acceptable and practicable eventoday.They are1. Aushadha Chikitsa (Employment of

medicinal remedies)2. Ksh ara Ch ik it sa- (Chemical

Cauterization).3. Agnikarma (Thermal cauterization)4. Sashrakarma (Surgical management).

Out of four therapeutic regimens, theKshara & Agni Karmas are regarded aspara-surgical procedures, which can becarried out without much preparation. InSushrut Samhita, we can also see someexternal applications apart from some oralremedies.

Keeping the treatment descriptionsgiven by Sushruta in view, pichuapplication IS selected for the study as perthe parameters set in the protocol.

Materials and Methods

A single blind pilot study wasconducted at Ano-rectal clinic of

C.R.I.(Ay.), Bhubaneswar using speciallydevised protocol & proforma, designed asper both Ayurvedic and modernparameters. Essentially the study aimed toevaluate the efficacy of the pichuapplication in terms of the days taken tocheck the bleeding as well as associatedsymptoms and to see the recurrence ofbleeding & other symptoms after completehealing.

A) Selection of cases: A total no. of 25patients with complains of bleeding perrectum during andlor after the defecationwith or without other symptoms like,itching, discharge, constipation, with lorwithout pain were examined per-rectallyand confirmed by proctoscopicexamination were admitted for the study.The cases of strangulated pile masses, andhaemorrhoids associated with malignancywere excluded from the study.

B) Preparation of Pichu: A plain rubbercatheter No. 7 is wiped with the soakedgauze (sterile) till it comes to the size oflittle finger and is secured by sterilesurgical thread.

1. Drugs used for pichu: Murivenna tail+ Jatyadi tail + Kasheesadi tail Theingredient in kaseesadi taila is having theproperties of Sodhana and Ksharana;Jatyadi taila is a good wound healer andMurivenna is being used by KeralaPhysicians as an anti-septic and also havingthe soothing effect and hence thecombination is selected

42

THE ROLE OF PICHU (TAILA) .....

2. Application of Pichu: After keeping-- the patient in lithotomy position the

proctoscope is placed per rectally. After thepicliu is inserted in to the anal canalthrough the lumen, the proctoscope is takenout immediately and the Pichu is kept forone hour. Thispichu is applied once in twodays and 10 applications of such are donein the period of 21 days.

3. Follow-up: After application of thepichu for 10 times all cases were followedup to 6 weeks to see the recurrence if any.,C) Diet:

To be taken: Ghee, milk, rice and plentyof liquids.

To avoid: Non-veg. and spicy foods.

D) Criteria adopted for assessment ofthe response of therapy:

Since the bleeding is the mainsymptom in the bleeding haemorrhoids, thedays taken to arrest the bleeding is notedalong with alleviation of other associated

.•. symptoms like Prolapse of pile mass,Itching / pruritis, discomfort, pain,discharge & anaemia (as shown in Table:III) and the result was assessed in thefollowing manner.

1. Complete relief: When the bleeding ischecked completely within 7 days oftherapy and complete disappearance ofassociated symptoms if any and norecurrence up to 6 weeks of the follow-up.

. 2. Marked relief: When the bleeding is

checked after 7 days but Before 14 days oftherapy and complete disappearance ofassociated symptoms if any and norecurrence up to 6 weeks of the follow-up.

3. Moderate relief: Arrest of bleedingafter 14 days but before 21 days of thetherapy and complete disappearance ofassociated symptoms if any and norecurrence up to 6 weeks of follow-up.

4.Mild relief: Arrest of bleeding after 21days but before 30 days and completedisappearance of associated symptoms ifany and no recurrence up to 6 weeks offollow-up.

5. No relief: No checking of blood before30 days or checked After 30 days and/orrecurrence even after complete recoveryfrom the symptoms.

6. Drop out/LAMA:

1. Discontinuation of the treatment duringthe trial.

2. Development of any seriouscomplications.

3. Aggravation of the disease.

Results and Conclusions

a. Condition of patients on admission:(Summarized in table -I)

Out of 25 patients admitted for study,28 percent were males while 72 percentwere females. Maximum of 44 percent ofcases fall under the age group of 21 - 30

43

M.Mruthyumjaya Rao, et al.

yrs while minimum of 4 percent under thegroup of 51 & above.

were of Vataprakriti, maximum no. ofpatients (88%) had constipated bowelhabits and almost all patients were non-vegetarians.

Among them about 72 percent were ofpitta prakriti while minimum 12 percent

Table I

.Condition of patients on admission:

SJ. Condition No. of patients (%)

Age group(in yrs.) Male Female

Upto 20 2(8.0) 0(0.0)

21-30 4(16.0) 7(28.0)

3 1-40 1(4.0) 6(24.0)

41-50 0(0.0) 4( 16.0)

51 & above 0(0.0) 1(4.0)

Total 7(28.0) 18(72.0)

Prakriti of patient No. of patients (%)

ficlfa 3(12.0)

Pitta 18(72.0)

Kapha 4(16.0)

Bowel habits No. of patients (%)

Regular 3(12.0)

Constipated 22(88.0)

Alternate bowel habits 0(0.0)

Dietary habit No. of patients (%)

Vegetarian 01(4.0)

Non-vegetarian 24(96.0)

A

B

c

D

44

THE ROLE OF PICHU (TAILA) .....

b. The characteristic of Arsh a Ihaemorrhoids on admission:(Summarized in table- II)

About 48 percent of patients had thedisease for at least one year and about 12percent of patients had previous analsurgery. The type of Arsha was intero-external in about 52 percent of patients;haemorrhoids were positioned at 3° clockin all cases. A maximum no. of 52 percentof Arsha was found to be of pittaja typefollowed by Raktaja and Sannipataja withthe incidence of about 16 percent each.

Table IICharacteristics of Arslta /

Haemorrhoids on admission

Incidence/Characteristics

Percentageof Patients(n = 25)

a) Duration ofdisease (yr.)

<11-22-3>3

No. ofpatients (%)12 (48.0)8(32.0)3(12.0)2(8.0)

b) H/O previoustreatment

MedicalSurgicalFreshfNone

No.ofPts. (%)15(60.0)3(12.0)7(28.0)

c) Type ofHaemorrhoids

ExternalInternalIntero external

No.ofPts. (OAI)3(12.0)9(36.0)13(52.0)

e) Type ofArsha No.ofPts. CYlI)

Vataja 1(4.0)Pittaja 13(52.0)Kaphaja 2(8.0)Sannipataja 4(16.0)Raktaja 4(16.0)Sahaja 1(4.0)

f) Position of No.ofHaemorrhoids Pts. ('Yo)(0' clock) (n=573)

3° clock 25( 100.0)5° clock 21(84.0)7° clock 23(92.0)11° clock 24(96.0)

c. Clinical findings noticed on

admission (Summarized in table No.III)

All patients had bleeding per rectum

and prolapse in 84 percent, 28 percent had

pruritis, 72 percent had discomfort at peri

anal region, 56 percent had pain during/

after defaecation, 76 percent had mucus

discharge. About 12 percent had the mean

hemoglobin of 6.3 gm, about 72 percent

had the mean Hb% of 7.3 gm% while

remaining patients (16%) had either mild

anaemia or normal level of haemoglobin

with mean of 10.5 gm%. About 60 percent

had moderate bleeding, about 8 percent and

32 percent had mild and profuse bleedmg

per rectum respectively.

45

MMruthyumjaya Rao, et el,

Table III

Clinical features (signs & symptoms)

noticed on Admission

( n=25)

SI. Symptom No. of pts.( 0/0)

A. Bleeding (25=100%)

Profuse/severe

Moderate

mild

8(32.0)

15(60.0)

2(8.0)

B. Prolapse of pile

masses 21 (84.0)

C. Itching! Pruritis 7(28.0)

D Discomfort 18(72.0)

E. Pain 14(56.0)

F. DIscharge (mucoid) 19(76.0)

G. Anaemia

Severe 3( 12.0)

(Hb(~;;,<7grn. %) (mean Hb%)

=6.3

Moderate 18(72.9)

(b%7-IOgm) (mean Hb)

=7.3

Mild/normalcy 4(16.0)

(Hb%> 10gm%) (rneanl-lb'z.)

=10.5

d) The speed of recovery from bleeding

and other associated symptoms

(Summarized in Tables from IV to IX) :

i) Healing took place 111 all 25 patients

with varying degree of d urat io n

starting from one week to four weeks.

Out of 25 cases about 80 percent

patients had healing (complete relief)

by 1st week, 12 percent had (marked

relief) by two weeks and 8 percent had

(moderate relief) by three weeks (Table

IV).

ii) Analysis was made about the response

in reference to the duration of the

disease and it shows 40 percent of

cases who had complete reliefhad the

duration of illness less than one year

and about 8 percent of cases who had

marked reliefhad illness less than one

year (Table V).

iii) A maximum no. of 52 percent of

Intero-external haernorrhoid cases had

complete relief and about 28 percent

of cases of internal haemorrhoids had

complete rei ief (Table VI).

46

THE ROLE OF P/CHU (TA/LA) .....

Table IVSpeed of Recovery from bleeding and other associated symptoms

Resu It / Recovery No. of patients Percentage

Complete reliefby 1 weekMarked reliefby 2 weeksModerate relief by 3 weeksMild reliefby 4 weeksNo relief after 4 weeks010P out / Recurrence

200302ooo

8012080.00.00.0

Total 25 100.00

Table V

Speed of recovery according to the duration of the illness (n=25)

Duration Results of tbe treatmentof illness No. of patients (Percentage)(in yrs.) CR MR MDR MLR NR DO Total

Up to I 10(40.0) 2(8.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 12(48.0)•1-2 05(20.0) 1(4.0) 2(8.0) 0(0.0) 0(0.0) 0(0.0) 8(32.0)

2-3 03(12.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 03(12.0)3&above 02(8.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 02(8.0)

Total 20(80.0) 03(12.0) 02(8.0) 0(0.00) 0(0.00) 0(0.0) 25 (100.00)

Table VISpeed of recovery according to the type of baemorrboids (n=25)

Type of Results of the treatmenthaemorrboid No. of patients (Percentage)

CR MR MDR MLR NR DO Total

Extemal 0(0.00) 01(4.0) 2(8.0) 0(0.00) 0(0.00) 0(0.00) 03(12.0)

Intemal 07(28.0) 02(8.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 09(36.0)

Intero-ext. 13(52.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 13(52.0)

Total 20(80.0) 03(12.0) 02(8.0) 0(0.00) 0(0.00) 0(0.0) 25 (100.0)

AbbreviationsCR = Complete ReliefMLD = Mild Relief

MR = Marked ReliefNR = No Relief

MDR = Moderate ReliefDO = Drop out

47

MMruthyumjaya Rao, et al.

iv) It has also been observed from thestudy that there is a signi ficant

improvement in hemoglobin levelsafter 45 days of the therapy (Table VB).

Table VII

Improvement in the Hemoglobin level (n=25)

Level of Hb% Hemoglobin onadmission

After 30 daysHboil.

After 45 days.Hb'V..

<7gm.% 03( 12)(mean=6.3gm. %)

0(0.0) 0(0.0)

7-10gm.% 18(72.0) 0(0.0) 0(0.0)(mean=7.3.%)

04 (16.0) 25 (100.0) 25( 100.0)(mean=10.5) (mean= 10.8) (mean=12.5)

>10 gm.%

Table VIII

Improvement in different signs & symptoms (Parameters)at the end of the study

SI. Parameters No. of relieved subjects at theNo. end of the study No.(%)

01. Bleeding (n=25) 25( 100.0)

02. Prolapse of pile masses (n=21) 17(80.95)

03. Itching/ Pruritis (n=7) 7(100.0)

04. Discomfort (n=18) 17(94.44)

05. Pain (n=14) 14(100.00)

06. Discharge (n= 19) 18(94.73)

* Total mean percentage of cure at the end of the study is 95.02

48

THE ROLE OF P/CHU (TA/LA) .....

Discussions

The Haemorrhoids are regarded as asurgical disease and there are manyoperative and para-surgi~al techniques arein practice, and most of oper a ti veprocedures involve risk factors and hencehave their limitations. In view of above tofind out a non-invasive, conservativeAyurvedic drug regimen In themanagement of Arsha and owing to theproperties of drugs, taila pic/ILl has beenselected and kept for study.

..•.

Usually taila will help in producing asoothing effect and will help easy descentof the faecal column. The main ingredientof Kasheesadi taila is Kaseesa (Co S04)and the effect of Kaseesa is known asSodhana and Ksharana which helps inhealing of the eroded portion of thehaemorrhoidal vessels and facilitates &

promotes quick healing. The Physicians ofKerala are using' Murivenna tai/a'successfully for quick healing of internaltraumas (bonelmusclelligament etc.) andalso it is soothing in nature. It helps in easypassage of bowels without damagingfurther the lumen of the rectum. It also been

used as anti-septic, anti-infllammatory andhence helps in reducing the size of the pilemass, reducing the vascosity & thrombosisofhaemorrhoidal vassels, Jatyadi taila hasa potent wound healing properties andhelps in repair of eroded surfaces of the

hemorrhoidal vessels and mucosal liningof the ano-rectal canal.

Secondly, the pressure exerted by thepichu helps in mild dilation of the analcanal as well as the sphincter which helpsin reduction in the size of the prolapsedpile mass, as well as proper penetration andabsorption of the oils.

Since the earlier studies revealed therefined foods, fast foods and non veg. dietrises the incidence of hemorrhoidalbleeding, the patients were kept on Milk,rice diet and plenty of liquids which alsohelps in the prevention of the recurrence.

On the basis of the results of this singleblind pilot study, it is concluded that theearlier the chronicity of the disease, thequicker the healing and also minimum ornegligible chances of recurrence. Afteranalyzing the results, it is concluded thatthe pichu application is encouraging in themanagement of Arsha. Since it is a pilotstudy involving only 25 patients, to see itsrole in more scientific way, more numberof cases is required to draw a finalconclusion.

Acknowledgment:

The authors are highly indebted to thedirector, CCRAS, New Delhi. We are alsothankful to the patients who gave theirconsent to carry out the study.

49

MMruthyumjaya Rao, et et.

H.G.Anderson

Burkitt

L.P.Fielding et al.

S.K.Sharma et al.

B.N.Sharma

Rob & Smith

M.Stanely.Goldburg et al.

Susruta, Susruta Santhita

1.M.Watts, et al.

1909

1972

1994

1999

1980

1965

REFERENCES

The after results of the operative treatment of

haernorrhoids pre.medJ.2: 1276.

Varicose vein, Deep Vein thrombosis and

Haemorrhoids (Epidemiology and Suggested

Etiology,) Br.M.l.2,556

Management of patients with symptomatic

haemorrhoids an introduction - (page 462-63)

Kshara sutra therapy in Fistula-in-ano and

other Ano rectal diseases Rastreeya Ayurveda

Vidyapeeth publication, New Delhi

Ayurvedic management of Ars h a

(Heamorrhoids)-CCRAS publication

Operative surgery Lippin cott company-4th

edition.

Annals of Ano - Rectal Surgery, 1.P.

publication

Chawkamba Sanskrit Series Office, Varanasi.

(commentary by Ambika dutta Sastri),

A controlled study of pain after di fferent forms

of Haemorrhoidectomy, Surg,gynoec,

obstet.120: 1037.

50

THE ROLE OF PICHU (TAILA) """""

3M if ~ fl:t:! ~ ~ lR ~ ~ ~

~. ~\iS"\if1i1 WT, ~. Gffi, \ifi.~.Gffi ~ ~.~.~

~ Wm Lf?f if xcrul~l LR -ffi;r ~ cfi ~ LR ~ ~

3f~ fcpm Tfm t I C[C1 25 xl R'I di LR <T6 3f~ ~ Tfm I ~3f~ if Rl PcPru I cfi ~ 3f~ -gg «m ~ ~ cfi ~ ~ em

, ~ ~ lSI'11(OJI Tfm t I Rl PcPRi I ~ xi urol ~ cnc{ 25 xl R'I <:ll" if~ 98.02 qfc1~ld x'IR'I<Ti if ~ ~ c=rW3F<l xlR'l<:ll· if fllJ:JI.-(Ojd'l! ~

xi IJ:JIr[j w-nq 1Wn Tfm t I

51